CIHM 
Microfiche 
Series 
(l\/lonographs) 


ICIVIH 

Collection  de 
microfiches 
(monographies) 


m 


Canadian  Institute  for  Historical  Microraproductions  /  Institut  Canadian  do  microroproductions  historiquas 


1996 


Technical  and  Bibliographic  Notes  /  Notes  technique  et  bibllographlques 


The  Institute  has  attempted  to  obtain  the  best  original 
copy  available  for  filming.  Features  of  this  copy  which 
may  be  bibliographically  unique,  which  may  alter  any  of 
the  images  in  the  reproduction,  or  which  may 
significantly  change  the  usual  method  of  filming  are 
checked  below. 


D 

D 

D 

D 
D 
D 

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Q 

D 

D 


D 


Coloured  covers  / 
Couverture  de  couleur 

Covers  damaged  / 
Couverture  endommagee 

Covers  restored  and/or  laminated  / 
Couverture  restauree  et/ou  pelliculee 

Cover  title  missing  /  Le  titre  de  couverture  manque 

Coloured  maps  /  Cartes  g^raphiques  en  couleur 

Coloured  ink  (i.e.  other  than  blue  or  black)  / 
Encre  de  couleur  (i.e.  autre  que  bleue  ou  noire) 

Coloured  plates  and/or  illustrations  / 
Planches  et/ou  illustrations  en  couleur 

Bound  with  other  material  / 
Rem  avec  d'autres  documents 

Only  editkjn  available  / 
Seule  editk)n  disponible 

Tight  binding  may  cause  shadows  or  distortion 
along  interior  margin  /  La  reliure  serrde  peut 
causer  de  I'ombre  ou  de  la  distorsion  le  long  de 
la  marge  interieure. 

Blank  leaves  added  during  festoratk>ns  may  appear 
within  the  text.  Whenever  possible,  these  have 
been  omitted  from  filming  /  II  se  peut  que  certaines 
pages  blanches  ajoutees  tors  d'une  restauration 
apparaissent  dans  le  texte,  mais,  kxsque  cela  etait 
possible,  ces  pages  n'ont  pas  ^  filmees. 


L'Institut  a  microfilm^  le  meiiieur  examplaire  qu'il  lui  a 
6te  possible  de  se  procurer.  Les  details  de  cet  exem- 
plaire  qui  sont  peut-6tre  uniques  du  point  de  vue  bibli- 
ographique,  qui  peuvent  modifier  une  image  reproduite, 
ou  qui  peuvent  exiger  une  modifications  dans  la  meth- 
ode  nonmale  de  filmage  sont  indiquds  ci-dessous. 


D 
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n 
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Coloured  pages  /  Pages  de  couleur 

Pages  damaged  /  Pages  endommagdes 

Pages  restored  and/or  laminated  / 
Pages  restaur^es  et/ou  pellicuiees 

Pages  discoloured,  stained  or  foxed  / 
Pages  decolorees,  tachetees  ou  piquees 


I     I      Pages  detached  /  Pages  d^chees 
("7]      Showthrough/ Transparence 

□     Quality  of  print  varies  / 
Qualite  inigale  de  I'impression 

I     I      Includes  supplementary  material  / 
' — '      Comprend  du  materiel  supplementaire 

□  Pages  wholly  or  partially  obscured  by  errata 
slips,  tissues,  etc.,  have  been  refilmed  to 
ensure  the  best  possible  image  /  Les  pages 
totalement  ou  partiellement  obscurcies  par  un 
feuillet  d'errata,  une  pelure,  etc.,  ont  ete  filmees 
a  nouveau  de  fafon  a  obtenir  la  meiileure 
image  possible. 

Opposing  pages  with  varying  colouration  or 
discolourations  are  filmed  twice  to  ensure  the 
best  possible  image  /  Les  pages  s'opposant 
ayant  des  colorations  variables  ou  des  decol- 
orations sont  filmees  deux  fois  afin  d'obtenir  la 
meiiieur  image  possible. 


D 


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Addftional  comments  / 
Comment^res  supp)enient£ures: 


This  ittm  is  filmed  at  tht  rtduction  ratio  checked  below/ 

Ce  document  eii  fitme  eu  taux  de  reduction  indiqui  ct-destous 


lOX 

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22X 

26  X 

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tzx 


2<X 


Th*  copy  fllm«d  h«r»  lw»  b««n  raproduead  thank* 
to  tha  ganarotity  ol: 

D.B.  WtMon  Llbraiy 
Unixnity  of  Wtiurn  Ontario 

Tha  Imagaa  appaaring  hara  ara  tha  baat  quality 
poailbla  conildaring  tha  eondltlon  and  lagibllltv 
of  tha  original  copy  and  In  kaaping  with  tha 
filming  contract  apacif leatlona. 


Original  capiat  In  printad  papar  covart  ara  Hlmad 
baginning  with  tha  front  eovar  and  anding  on 
tha  latt  paga  «vlth  a  printad  or  llluttratad  Impraa- 
aion.  or  tha  back  cowar  whan  appropriata.  All 
othar  original  copiaa  ara  fllmad  baginning  on  tha 
firat  paga  with  a  printad  or  llluttratad  Imprat- 
alon,  and  anding  on  tha  laat  paga  with  a  printad 
or  illuatratad  impratalon. 


Tha  latt  racordad  frama  on  aach  mieroflcha 
thall  contain  tha  tymboi  —^  Imaaning  "CON- 
TINUED"!, or  tha  tymboi  V  (moaning  "END"), 
whichavar  appllat. 

Mapt,  platat.  charu.  ate.,  may  ba  flinad  at 
diffarant  raduetlon  ratlot.  Thota  too  larga  to  ba 
antlraly  ineludad  in  ona  axpoturo  ara  fllmad 
baginning  In  tha  uppar  laft  hand  comar,  iaft  to 
right  and  top  to  bottom,  at  many  framat  at 
raqulrad.  Tha  fallowing  diagramt  llluatrata  tha 
mathod: 


1 

2 

3 

1 

2 

4 

5 

L'Mamplair*  film*  fut  rapreduit  grte*  t  la 
ftnttoaltt  da: 

D.B.  WaMon  Library 
Univanlty  of  Wnttm  Onttrio 

Lat  imaga*  luivantas  ont  at*  raprodultas  avac  la 
plui  grand  toin,  eompta  tanu  da  la  condition  at 
da  la  nattata  da  I'axamplalra  filma.  at  an 
conformlta  avae  laa  eondltlona  du  contrat  da 
flimaga. 

Laa  axamplalroa  origlnaux  dont  la  eouvanura  an 
papiar  aat  Imprimaa  aont  fltmis  an  eommanfant 
par  la  pramlar  plat  at  an  tarmlnant  loit  par  la 
darnMra  paga  qui  comporta  una  amprainta 
d'impraaalon  ou  d'llluatratlon,  toit  par  la  sacond 
plat,  aalon  la  eaa.  Toua  laa  autraa  axamplairaa 
origlnaux  aont  filmaa  an  eommanf ant  par  la 
pramMra  paga  qui  comporta  una  amprainta 
d'impraaalon  ou  d'illuatratlon  at  an  tarminant  par 
la  darnMra  paga  qui  comporta  una  talla 
amprainta. 

Un  daa  aymbolaa  auivanta  apparaitra  «ur  la 
darnMra  Imaga  da  chaqua  microfieha,  talon  la 
cat:  la  aymbola  —^  signifia  "A  SUIVRE ",  la 
aymboto  7  algnlfia  "FIN". 

Laa  cartaa.  planchaa,  tablaaux.  ate,  pauvant  ttra 
filmaa  t  daa  uux  da  rMuetion  difftranta. 
Loraqua  M  documant  aat  trop  grand  pour  ttra 
raproduit  an  un  aaul  clicha.  il  aat  filma  a  partir 
da  I'angla  nupariaur  gauctia.  da  gaucha  i  droita, 
at  da  haut  an  baa.  an  pranant  la  nombra 
d'imagaa  nicaaaaira.  Laa  diagrammaa  auivanta 
illuatrant  la  mathoda. 


2 

3 

5 

6 

MKtOCOrr   HSOWTION   TIST  CMART 

(ANSI  and  ISO  TEST  CHART  No.  2) 


1.0 


I.I 


Ik 
12.0 


i^n^il 


A     •APPLIED  IM^OE     Inc 

^S        1653  Eo«t  Uoin  Sl'««l 
r^g        (716)   *8i  -  D»0  •  fhont 


J 


(  Medical  Journal,  [muc  rf 


WHY  Tl;!.:  DKUW  IN-  liKCOCf NIZIXO 
rj)(()M()TOI{  ATAXIA?* 

e.  F.  np.i',  jr.  [)., 


ri>fesHn.-  of  N'civous 
I'nivtrsily    Sehuii! 


n(i  Mental  Uiteascs,   Indi.i 
^f    Mediiinc. 


It  irmy  scoin  priwiirnplnoiis  fur  one  to  tnko  up 
till'  tiuir  jin.l  iittiMitioii  of  this  mccthif;  in  morelv 
trying  to  liiy  empliiisis  upon  oonclitions  which  are 
airoafly  well  known  to  all  of  us,  ami  which,  too, 
niaiiy  of  us  take  for  j;rniiteil,  arc  or  should  be 
known  Ity  every  one  ainiin;^  to  practice  rnedicine. 
hut  judging  from  the  frecpiency  with  which  tlie 
early  manifestations  of  locomotor  ataxia  aie  at- 
tiibuteil  to  and  treated  for  some  entirely  different 
ibseascd  condition,  it  is  evident  that  more  atten- 
tion should  be  given  to  this  disease  and  allied 
conditions,  and  greater  stress  placed  upon  the 
importance  of  the  early  recognition  of  such 
symptoms  as  are  usually  found  in  the  early  stages. 
Furthermore,  since  it  is  well  known  that  •■■/hen 
once  the  destructive  changes  in  the  neurons  of 
the  central  nervous  system  have  taken  place, 
no  form  of  treatment  can  restore  tlicm,  and  since 
the  pathological-anatomical  changes  in  this  dis- 
eiiae  are  ultimately  deiitructive  in  character,  it  is 
only  too  evident  that  tlie  cailier  the  character  of 
the  disease-process  is  recognized  and  appropriate 


*Kea<i    at    nieiting 
July  li.  11*15. 


if   .\Henists  and   XeiiruloKist^   Chicago, 


treatment  idtninwtered  to  interrupt  or  inhibit 
the  activity  of  the  cauftative  factors,  the  apiro- 
diacte  pallida  or  the  tovic  products  of  iti  activity, 
tlie  better  will  be  the  reaulta  of  that  treatment. 
Mneting  io  frequently  with  patient*  complaio- 
ing  of  symptoma  which  point  incontrovertibly  to 
the  tabeiic  condition,  and  who  had  complained  of 
them  for  j?ars  and  yet  the  probability,  often  not 
even  the  poii'bility  of  the  diaeaae  conaidercd,  one 
iiaturally  eeekk  for  lome  explanation.  Two  fac- 
tor) aeem  to  atind  out  predominantly:  One  ii 
the  statement  uiually  made  by  the  attending 
physician  that  kn.iwing  the  patient  «o  well  he  did 
not  believe  a  syphilitic  infection  possible,  so  did 
not  suspect  it,  or  where  suspected  and  inquiry 
made,  was  given  a  positive  denial  either  inten- 
tionally or  from  ignorance  thereof  due  to  the 
triviality  of  the  manifestations  at  the  time  of  in- 
fection. The  other  factor  seems  to  be  the  fault  of 
ufl  neurologists  and  alienists  in  failing  to  empha- 
size sufficiently  the  necessity  of  always  having  in 
mind  the  possibility  of  a  tabetic  process  where 
one  meets  with  manifestations  well  indicative  of 
it.  With  the  means  at  our  disposal  jt  the  present 
time,  there  is  practically  no  excuse  for  failure  to 
recognize  the  tabetic  condition  until  the  process 
has  advanced  to  that  stage  where  all  who  run  may 
read.  The  object  of  this  paper,  therefore,  is  not 
to  add  anything  new  to  our  knowledge  of  the  dis- 
euse,  but  to  eniphasite  the  necessity  of  recognis- 
ing early  the  eharactc-  ar.a  nature  of  those  con- 
ditions which  indicate  the  existence  of  the  tabetic 
process.  In  our  eagerness  and  desire  to  win  fame 
and  honor  by  discovering  something  new  or  start- 
ling, something  heretofore  unknown  or  unthought 


J 


..f  we  ,m  tou  iijit  tci  ni.((lfit  the  more  importnnl. 
....rrimi.  ,  n,ry\.n-  pliwiomonn,  at  tho  expcnie  of 
tlw  |iiili..rit'«  liealth  ami  happiiiw*.  n  [,  „„(  tho 
mtijtii.ri  to  I'liui.'i.rntf  uvpry  nianir™tntion  tliat 
11  ni.i  will,  i„  tlic  I'arlv  .I,-,.;..,  of  the  ..isoasf,  nor 
Im  liiw  1.™  in  .Mail  indiviii'..  ,1  ,■;,«,,  but  a  a.vnop- 
tical  oiillino  of  the  early  lii.tory  of  a  few  illus- 
liative  eases  an  aseertainwl  l,y  examination  will 
lie  ^Mveii,  pointin:;  out  tile  unileccMarv  ilela.v  that 
oe.iirre.l,  „nil  eallijiK  attention  .o  tllo.e  features 
nhieh  slioukl  have  direetcil  the  attention  of  thi' 
phvsieian  to  the  powihility  of  a  tabetie  process, 
"itii  a  notation  of  the  conditions  eiistirg  at  tlii' 
nrrie  of  cxamiDaton. 

Cajc  I.    Male.  aRcd  fitly  ytan.    He  gives  a  his- 
tory of  a  posiibic  infection  at  Ihirly-five,  Ihe  physi- 
cian at   thai  lime  calling  a  local  penile   ,ore  merely 
a    so-called    jofl    rhancre.     During    the    last    ten    to 
twelve  years  he  has  complained  of  more  or  less  pain 
in  Ihe  legs,  more  about  the  knees,  vaiying  in  severity 
intcrmiltcnt  in  action    dull  and  aching  in  character 
Uiiially  relieved  by    ,  course  of  hot  baths  or  similar 
treatment.     I- our   years   ago    following   an   attack   of 
gonorrhea   w,-ich   became   chronic,   he   suffered    from 
what  was  called  a  nervous  breakdown  which  was  at- 
tributed 10  the  passage  of  sounds  in  the  course  of  the 
treatment.    Alter   four   to   five   months   he   began    to 
notice  a  difficulty  in  going  up  and  down  stairs ;  also 
pain  across  Ihe  arch  of  the  foot  and  ankles,  this  being 
attributed  to  Ihe  condition  of  falling  arch  and  lal- 
f'^otedness.     During  the  last  two  to  three  years  ,   is 
ccndilion    has    gradual'-    grown    worse.     The    pains 
wer>  worse  at  night  ai.d  at  changes  of  weather.     He 
became  more  nervous,  was  olicn  unable  to  sleep  be- 
"■-use  of  the  pains;  noticed  a  loss  of  sexual  power 
at  ti-es  difficulty  in  controlling  the  bladder,  a  numb^ 
ecsi     n  the  fingers  .-id  hands,  less  so  in  the  feet:  a 
sense   of   early    (atijiue   after   eiercise,   of    weakness 
in  the  knees  and  stiffness  in  Ihe  feet,  and  a  tendency 


tn  «t;iKRfr  when  first  RfttinR  on  hU  feel  !o  wilk 
I'lider  the  influence  o(  alcoholic  itimiilinti  the  diflfi- 
ciilty  in  gait  and  the  tcnsqry  ditturtnncei  apparently 
ilitappearcd  temporarily,  or  at  leait  he  became  un- 
cnscioui   of   their   pretence. 

Txamination  of  thl«  patient  diictosed  unequal  pupil- 
inaniffiting  the  Ariiyll-Koliertion  phenomenon  absent 
tendon  reflexes  in  both  armi  and  Icgi;  marked  Rom- 
brrg  swaying,  marked  ataxia  and  inco-ordination  in 
the  movements  of  the  arms  and  le«»;  a  loss  of  the 
sense  of  movement  in  the  toe  and  ankle  joints;  a 
marked  delay  in  the  perception  of  the  pinprick,  and 
a  more  or  lets  general  hyperesthesia  to  heat  and  cold, 
the  blood  and  spinal  fluid  each  gave  a  foiir-|iIti* 
positive  VVaasermann  reaction.  This  patient  duriiiR 
the  last  three  to  four  years  has  passed  through  the 
hands  of  several  phywcians.  osteopaths  and  chiro- 
practors, and  even  at  the  time  of  examination  hail 
been  referred  tn  a  surgeon  for  advice  and  treatment 
in  regard  to  the  falling  arirhes,  which  we  c  regarded 
as  the  seat  of  the  trouble.  The  loss  of  bladder  con- 
trol and  of  sexual  power  was  attributed  to  the  in- 
discriminate use  of  the  urethral  soun**;.  The  pain* 
in  the  feet  and  legs  and  the  difficulty  in  walking 
wrre  attributed  to  the  falling  arches,  and  the  general 
n-  .usness  due  to  the  pain  and  the  disturbance 
(  I  sleep. 

The  early  paina  in  this  patient  were  undoubt- 
t'llly  tabetic  in  origin,  since  iHcy  were  not  arthri- 
tic, had  not  the  charttct*r  of  a  peripheral  neuritis, 
wiro  transitory  in  duration,  changeable  in  char- 
acter, not  nfi.«iK-iated  with  any  local  dirtturbances, 
and  showed  a  tendency  to  be  worse  at  night  and 
during  changes  of  weather.  Tliese  featnres  taken 
individually  may  not  mean  much,  but  taken 
rolleetively  arc  almost  pathognomonic  of  tabetic 
pains.  It  is  quiie  probable  that  had  a  proper  ex- 
amination been  made  when  these  pains  first  ap- 


.J 


pfun'J  iIhtp  wotilil  liiiv.>  I ti   t'*uu*\  other  i*vi- 

lUucfn  (t(  till'  [inwni'c  of  e(.    tdlM-tic  iim.'sn. 

Ca«  U',  Male,  aitnl  foriy-fivc  yttra.  IU«tnry  ..f 
luetic  iiifrction  clcvrn  years  ago.  Three  year*  aifo  In- 
iHljati  to  have  aHaik-.  of  pain  in  the  upper  abdominal 
regirm,  located  mo«'  between  the  median  line,  th« 
level  i»f  the  utntiili.  ,  and  the  rinht  cntlal  mariiin. 
The  paini  were  sudden  in  on«t,  upavmodic,  (jrininK  in 
character,  were  aivocialed  with  naii«ea  and  vomitiiiK. 
were  relieved  only  oy  opiatet,  were  not  followed  I>y 
any  Ir  -al  loreneis  ur  teniI(Tiie!i!i  and  recurud  at  nr»t 
at  ii>  lir  intcrvalt.  hut  ..f  hite  they  have  wen  mnre 
(requen  .  occurring  alnmt  every  week  or  ten  daj* 
This  patient  wa^  treated  by  neveral  physician*  fur 
gastric  and  for  gall-bladder  discaic.  He  had  als.. 
cnniiutled  several  siirReons,  who  also  diagnosed  gall- 
bladder Hiseaie.  probably  calculus,  and  had  advistil 
nperation. 

At  the  time  of  exap  .ition  there  was  found  the 
Argyll-Robertson    pupi  slight    Romberg    swayipg. 

absence  of  the  patella  ^nd  Achilles  tendon  reflexes, 
anesthesia  over  the  outer  =de  of  both  legs,  retarda- 
tion of  pain  and  pressure  &ense  in  both  feet  and  legs. 
The  abdominal  examination  was  negative  r  -  at  Ica^l 
•'oubtful. 

From  these  clinical  data  the  diagnosis  -  tabetic 
crisis  was  midc.  As  this  was  before  the  ent  «f 
the  Wassermann  reaction,  or  before  much  attention 
was  given  to  the  spinal  fluid  for  luetic  states,  no  data 
are  at  hand  in  this  regard. 

The  family  physician  disagreed  with  the  diagnoisi^, 
and  when  the  surgeon  who  had  referred  the  patient 
for  a  neurolugical  examination  declined  to  operate 
he  persuaded  the  patient  to  submit  to  an  operation, 
but  failed  to  find  any  evidence  of  a  surgical  patholog- 
ical process  in  the  abdominal  cavity.  Also  the  sub- 
sequent history  of  the  patient'^,  illness  proved  it  to  lie 
wholly  tabetic  in  origin. 

It  is  not  iinrommmi  to  meet  with  cases  of 
locomotor  ataxic  in  whidi  acute  pains  of  this 
type  an.l  character  are  tiie  first  manifestations 


tiiat  lead  the  patient  to  sook  modical  advice,  al- 
though close  interrogation  will  usually  disclose 
the  presence  of  other  disturbances  wliich  had  ex- 
isted for  a  variable  length  of  time,  but  were  not 
dufRcicntly  prominent  to  attract  much  attention 
or  cause  much  disconifurt  or  distress.  When  such 
iievere  pains  are  more  or  less  constantly  located 
in  one  or  other  of  the  special  organs  they  consti- 
tute the  more  common  form  of  the  so-called 
tabetic  crisis.  But  it  must  be  borne  in  mind  that 
pain  is  not  the  only  way  in  which  such  a  crisis 
luay  manifest  itself.  The  pain  may  be  entirely 
wanting,  and  in  its  place  there  may  appear  an  un- 
controllable vomiting,  an  unexplainable  diarrhea, 
a  profuse  polyuria,  an  unsiratifiable  erotic  sensa- 
tion, etc.,  any  one  of  wluch  may  be  the  only 
prominent  manifestation  in  the  earlier  stage  of 
the  disease. 

Case  3.  Female,  aged  forty-five  years.  W^dow  of 
an  army  officer.  Ten  years  before  the  time  of  ex- 
amination she  suffered  from  an  attack  of  herpes 
zoster  completely  encircling  the  body  at  the  watst- 
Iti-.e,  following  which  there  persisted  a  feeling  of 
hi-aviness  and  of  a  band-like  constriction.  About  a 
yi^ar  later  she  began  to  have  pains  in  both  heels,  sud- 
den in  onset,  transitory  in  duration,  and  stabbing  in 
character.  Later  these  extended  up  the  inner  side 
of  the  legs.  Two  years  later  she  began  to  notice  a 
difficulty  ill  walking,  particularly  at  night,  describing 
it  as  a  feeling  or  sensation  as  if  on  skates,  also  a 
numbness  in  the  whole  lower  extremities. 

Various  physicians  were  consulted  and  she  spent 
several  years  in  various  sanitarias,  her  condition  bt- 
ing  regarded  as  a  nervous  breakdown  incident  to  the 
approaching  menopause. 

Exami.iation  disclosed  unequal  pupils,  the  Argyll- 
Robertson  phenomenon,  absent  patellar  and    Achilles 


ti'iidon  refltxes,  paresthesia  of  the  lower  extrcmitifs. 
a  marked  RomhcrK,  marked  ataxia  and  incoordina- 
tion, and  the  hlood  gave  a  four-plus  pi>sitivc  Uasser- 
Pinnn  reaction. 

The  patient  gave  a  neRative  history  and  bitterly 
risented  any  suRgestion  of  it  being  syphilitic  in  origin 
after  having  insisted  that  she  be  told  deriiiitely  and 
specilically  the  nature  and  origin  of  her  trouble.  In 
this  idea  that  the  di.scased  condition  could  not  pos- 
sibly  be  syphilitic  in  origin  she  was  supported  by 
stiveral  physicians  who  had  previously  treated  Ikt, 
.''is  a  result  of  this  disagreement  she  discarded  medi- 
cal advice  an<l  tcok  up  Christian  Scienn-  for  severril 
years,  hut  finding  herself  gradually  growing  worse 
she  later  accepted  the  situuli.n  more  philosophically 
and  decided  to  secure  what  relief  was  possible  by 
appropriate  treatment. 

It  eun  scareoly  be  iiiH'stiiuicil  tliiit  the  liilateral 
zMstei  follonofl  by  ji  |H'i-ii.-;tinii  fc-ciiii;;  of  lioavi- 
iM'ss  and  jiinMe  sensation  was  a  direct  result  and 
manifestation  of  the  inci|iient  tahotic  process. 
«nd  it  is  pniltaide  that  liad  a  proper  examination 
I'cen  made  at  that  time  tiio  speeifie  nature  of  tlio 
trotihle  wiinld  have  htn-n  recofiriizod  and  all  tlie.sc 
years  would  not  have  elapsed  hefore  hein^  placed 
niider  proper  treatment. 

Case  4.  Male,  aged  thirty-one  years.  History  of 
infection  twelve  to  liftcen  years  before.  Three  years 
ago  the  left  eye  turned  inward,  causing  double  vision, 
lasting  several  days.  Kight  months  ago  he  began  to 
notice  a  dimness  of  vision  in  the  left  eye,  gradually 
growing  worse,  and  five  months  later  also  involving 
the  right  eye.  .About  this  time  he  began  to  notice 
some  difficulty  in  walking,  especially  at  night;  a  teii- 
d.ncy  to  fall  and  an  inability  to  tell -^  the  position 
of  the  feet  when  the  eyes  were  closed. 

When  the  visual  disturbance  first  began  he  con- 
sulted an  optometrist,  who  fitted  him  with  glasses, 
but  receiving  no  benefit  they  were  changed  from  time 
lo  time.     Finally,  he  consulted  an  oculist  who  recog- 


niaed  the  nature  of  the  trouble  and  advised  him  to 
consult  a  neurologist. 

Examination  disclosed  an  advanced  optic  atrophy 
with  practically  complete  blindness  in  the  left  eye  and 
almost  complete  bhndness  in  the  right  one;  unequal 
pupils  not  reacting  to  light,  but  reacting  to  accommo- 
dation attempts,  marked  Romberg  swaying;  absent 
tendon  reflexes,  delayed  pain  sensation;  loss  of  sense 
of  position  and  of  movement;  impaired  percepiion  of 
touch  and  temperature.  Wassermann  spinal  fluid  ex- 
aminations were  not  made,  as  the  patient  was  seen 
before  the  advent  of  the  Wassermann  reaction. 

Paresis  or  paralysis  may  occur  early,  involving 
either  a  single  muscle  or  part  or  all  of  a  function- 
ally associated  group  of  muscles,  or  involving  all 
or  only  part  of  the  distribution  of  a  peripheral 
nerve.    These  paralyses  are  usually  transient  in 
duration,   recovering  in  a   few  days,  weeks  or 
months,  and  may  be  paroxysmal  or  periodic  like 
the  pains   (Pitres),  assuming  an  apoplectiform 
character.    There  may  be  a  mere  sense  of  fatigue, 
■  a  fatigue  out  of  all  proportion  to  the  amount  of 
muscular    exercise,    this    often    preceding    for 
months  the  onset  of  a  definite  paralysis.    Of  these 
paralyses  those  involving  the  ocular  group  of 
muscles  are  probably  the  most  frequently  affected. 
Impairment  of  the  pupillary  reflex,  particularly 
to  light,  sometimes  also  to  accommodation,  is  one 
of  the  earlier  and  most  constant  findings,  the 
time  of  disappearance  of  the  pupillary  response 
being  very  difficult  to  fix,  as  it  is  usually  absent 
by  the  time  examinations  arc  made. 

Case  5  Male,  aged  fifty-two  years.  Denied  syphi- 
litic infection.  About  a  year  ago  he  began  to  suffer 
from  more  or  less  stomach  trouble  and  was  treated 
for  the  usual  "indigestion."  The  following  wmter 
after   the    stomach    trouble   had    existed    about    six 


-9— 


months  lie  contracted  n  severe  attack  of  influenza,  fol- 
lowing whicli  there  developed  urinary  incontinetia- 
which  was  subject  to  remissions.  Two  months  later 
he  hcgan  to  notice  a  difficulty  in  walking  and  a  feeling 
of  weakness  or  giving-way  of  the  knees  at  times. 
Examination  disclosed  the  presence  of  the  Argyll- 
Robertsoti  pupil,  absent  patellar  and  Achilles  re- 
flexes, incoordinate,  atiixic  gait,  loss  of  control  of  the 
vesical  sphincter,  a  positive  Wuscrmann  of  the  blood 
and  spinal  tluid;  the  latter  also  containing  an  excess 
of  protein  content  and  a  cell  count  of  abottt  ino  per 
c.mm. 

Disturbance  of  the  bladder  control  or  of  the 
sexual  function  is  not  an  infrefjuent  early  symp- 
tom nnri  shouM  always  arouse  suspicion  of  a 
possible  lues.  Difficulty  in  expulsion  or  in  re- 
tention of  the  urinary  flow,  abnormally  active 
erotic  sensations,  causelop^s  erections  and  emis- 
sions, sterility  in  fenifiles.  etc.,  arc  some  of  the 
more  common  disturbances  of  these  function:*. 

It  is  not  necessary  to  burden  you  with  more 
illustrations  along  this  linr.  Those  that  have 
been  given  serve  to  illustrate'  one  of  the  most  im- 
portant points  it  is  desired  to  make;  namely,  that 
in  practically  all  cases  of  locomotor  atavia  there 
is  an  unnecessary  and  uncalled-for  delay  in  the 
recognition  of  the  tabetic  or  syphilitic  nature  of 
the  earlv  manifestations.  I  am  satisfied  that 
this  is  the  experience  common  to  all  of  you,  and 
certainly  calls  fur  greater  effort  on  the  part  of 
those  teaching  neurology  and  psychiatry  and 
those  of  us  who  are  a.ssu(ning  to  be  neurologists 
and  alienists,  in  directing  attention  to  those  con- 
ditions which  shouhl  always  lead  one  to  bo  on  the 
lookout  tftr  a  luetic  involvement  of  the  nervous 
6  Vetera. 


